'Striking gap in health between rural and urban Americans'

Action Points

The approximately 46 million Americans living in rural areas are more likely to die from five leading causes, including heart disease and cancer, than their urban counterparts.

Note that targeted, needs-based prevention efforts combined with improved access to treatment for chronic conditions might help address the gap and reduce the number of excess deaths, according to the CDC.

The approximately 46 million Americans living in rural areas are more likely to die from the nation's five leading causes, including heart disease and cancer, than their urban counterparts, according to a CDC study.

In 2014, many deaths among rural Americans were potentially preventable, including 25,000 from heart disease, 19,000 from cancer, 12,000 from unintentional injuries, 11,000 from chronic lower respiratory disease, and 4,000 from stroke. The percentages of deaths that were potentially preventable were higher in rural areas than in urban areas, reported Ernest Moy, MD, of the CDC in Atlanta, and colleagues in the Morbidity and Mortality Weekly Report (MMWR).

"This new study shows there is a striking gap in health between rural and urban Americans," said Tom Frieden, MD, MPH, CDC director. "To close this gap, we are working to better understand and address the health threats that put rural Americans at increased risk of early death."

In a MMWR companion paper, Macarena C. Garcia, DrPH, also of the CDC, and colleagues stated that, "targeted, needs-based prevention efforts combined with improved access to treatment for chronic conditions," might help address the gap and reduce the number of excess deaths.

In the first paper, mortality data for U.S. residents from 1999 to 2014 was used to calculate age-adjusted death rates in rural and urban areas for the five leading causes of death. The findings showed that there were both higher age-adjusted death rates and greater percentages of potentially excess deaths in non-metropolitan areas.

During this time period, the age-adjusted death rates for heart disease, cancer, chronic lower respiratory disease, and stroke in urban areas decreased. In rural areas, the rates for heart disease, cancer, and stroke also decreased, but at a slower rate, and death rates increased for chronic lower respiratory disease. Across both urban and rural areas, the rates for unintentional injury increased.

Rural areas have higher rates of cigarette smoking, hypertension, obesity, physical inactivity during leisure time, and failure to use seat belts. Additionally, the poverty rate is higher in non-metropolitan areas as compared to metropolitan areas (18.1% versus 15.1 %), according to Moy's group.

There are concerns that these disparities will continue to grow, and efforts to improve healthcare access will be put in jeopardy, if the Affordable Care Act (ACA) is repealed.

"Speaking as a clinician, in the absence of any real plan to improve it, the dismantling of the ACA has the potential to be disastrous for patients, for providers, for the healthcare system, and for the American economy, and I think it is correct to infer that rural areas would suffer more," said Alan Ducatman, MD, of West Virginia University's School of Public Health in Morgantown. Ducatman, a former member of the West Virginia Governor's Advisory Council on Substance Abuse, was not involved in either MMWR report.

The urban versus rural classification scheme was based on the NCHS urban-rural classification scheme for counties. According to this method, approximately 15% of Americans currently live in rural areas. In the study, mortality data for U.S. residents was analyzed from the National Vital Statistics System. The researchers determined that approximately 62% of all U.S. deaths could be attributed the five leading causes of death.

The greatest gap was found in the category of unintentional death by injury, where the rate of death for rural Americans is 50% higher than for their urban counterparts. The authors suggested this gap could be partially attributed to the greater risk of death from motor vehicle accidents and opioid overdoses.

"The impact of the rural opioid epidemic has been a bigger negative factor than any positive in improved access can or has addressed," Ducatman noted.

More dangerous occupations such as farming, ranching, and logging skew more heavily toward rural areas, and the risks are exacerbated by a greater distance between healthcare facilities and trauma centers.

Screen patients for high blood pressure with control a quality improvement goal

Screen for cancer prevention and teach early detection with a focus on education, screening, access to care and support for cancer survivors

Encourage physical activity and healthy eating to reduce obesity

Educate and provide support for smoking cessation

Promote seat belt use and car seats

Practice safe prescribing of opioids for pain and educate patients on the risks of opioids

Garcia's group noted that work to reduce smoking and lower obesity rates was critical as these risk factors contribute to four out of five leading causes of death, with the exception of death by accidental injury.

They also pointed that needs-based allocation can substantially impact rural health. Although the research shows the increased risks in non-metropolitan areas, funding for these same factors is allocated on a population basis, leaving many rural areas lacking the funds to execute recommendations like the ones listed above, they stated.

Although not all excess deaths are preventable, the findings could signal a need for improved programs that support healthy lifestyles and communities or better access to healthcare services, according to Moy's group.

Moy, Garcia, and co-authors disclosed no relevant relationships with industry.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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